Effect of an electronic quality checklist on prescription patterns of prophylactic antiemetic and pain flare medications in the context of palliative radiotherapy for bone metastases

PURPOSE

International guidelines are available to guide prescription of antiemetic and pain flare medications in patients receiving palliative radiotherapy for bone metastases, but prescription rates are quite variable. We hypothesized that a simple electronic quality checklist could increase the evidence-based use of these medications.

MATERIALS AND METHODS

We implemented an electronic quality checklist item in our center for all patients treated with palliative radiotherapy for lumbar spine bone metastases. We retrospectively reviewed patients in the 6-month pre- and post-intervention. Patients were stratified according to if they were treated within a dedicated rapid palliative (RPAL) radiotherapy program or not. Chi-square tests were used to compare rates of antiemetic and pain flare medications pre- and post-intervention and RPAL vs not.

RESULTS

A total of 375 patients were identified with 42 (11.2%) treated in dedicated RPAL program. The proportion of patients treated with prophylactic antiemetic and pain flare medications pre-intervention (n = 226) and post-intervention (n = 149) was respectively 34.1% vs 59.1% (p < 0.001) and 26.1% vs 43.0% (p = 0.01). Observed differences for antiemetic prescription rates were greater for patients who were not treated within a dedicated palliative radiotherapy program, but this was not the case for pain flare medications.

CONCLUSIONS

Our data shows that a simple quality checklist item can have a significant effect on the evidence-based use of prophylactic antiemetic and pain flare medications in patients treated with palliative radiotherapy for bone metastases. We believe such strategies should be routinely included in other clinical pathways to improve the use of symptom control medications.

Impact of timing of administration of bone supportive therapy on pain palliation from radium-223

BACKGROUND

Skeletal-related events cause significant morbidity in patients with metastatic castration-resistant prostate cancer. In the ALSYMPCA study, radium-223 (Ra223) was found to provide pain palliation in addition to prolonged survival and reduced skeletal-related events (SREs). Given previous evidence that bisphosphonates impacted pain relief from the radiopharmaceutical samarium-153, we evaluated whether the timing of bone supportive therapy (BST) such as zoledronic acid or denosumab affected pain palliation from Ra223.

METHODS

We identified patients who received Ra223 at University of Southern California or Mayo Clinic Arizona. Patients were evaluable for pain response if they had baseline pain score > 0 and at least 1 pain score documented after Ra223 with pain medication use data. Patients were evaluable for pain flare if they had known baseline pain score and at least 2 pain scores documented after Ra223. Pain response was defined as > 2 point decrease in pain on a 10-point scale; flare was defined as > 2 point increase followed by return to baseline or lower.

RESULTS

Of 65 patients, 22 (34%) received BST. Median number of doses Ra223 was 5 (range 2-6). Fourteen patients were evaluable for pain response and 34 for pain flare. Eighteen patients received concurrent abiraterone (abi) or enzalutamide (enza), and 16 did not. Pain response occurred in 6/6 (100%) patients who received BST within 1 month prior to first Ra223 dose and 4/8 (50%) patients who did not receive BST. Pain flare occurred in 6/21 patients (29%) without BST and 2/13 (15%) with BST (p = 0.44). 6/10 (60%) patients with pain response had a decline in alkaline phosphatase (ALP) level, but there was no consistent pattern of ALP changes in patients with flare. 8/8 patients with pain response had no PSA decline. 6/8 (75%) and 2/18 (11%) patients on abi/enza had pain response and flare respectively, and 4/6 (67%) and 6/16 (38%) patients without concurrent abi/enza had response/flare.

CONCLUSIONS

BST within 1 month prior to first Ra223 dose was associated with increased likelihood of pain palliation and might prevent pain flare. Concurrent use of abi/enza was not associated with increased likelihood of pain response but was associated with decreased likelihood of pain flare.

An investigation into the incidence of pain flare in patients undergoing radiotherapy for symptomatic bone metastases

INTRODUCTION

External Beam Radiotherapy (EBRT) is a recognised intervention for symptomatic pain relief from bone metastases. Pain flare is a reported EBRT toxicity, described in 16-41% of steroid-naïve patients. This study aimed to determine incidence and duration of pain flare amongst patients within one Oncology Centre.

METHODS

Patients receiving EBRT for bone metastases were recruited to a prospective cohort study. Baseline pain scores and a daily pain/analgesia diary were recorded during EBRT and for 14 days thereafter. Pain flare was defined as a two-point increase on a pain scale or 25% increase in analgesia intake, with a return to baseline.

RESULTS

Of the thirty-two participants, 69% (n = 22) completed the diary. 41% (n = 9) patients experienced pain flare, the median duration being 3 days. Of the evaluable patients, 55% (n = 12) were male, 45% (n = 9) female. The median age was 73 years (range 40-83). The common primary sites of disease were Breast (32%) and Prostate (32%), with other sites making up the remaining 36%. The most frequent EBRT site was the spine (63%), with other treatment sites including pelvis (23%) and extremities (14%). EBRT regimes were restricted to 20 Gy in 5 treatments, received by 32% (n = 7) of patients and 8 Gy in 1 treatment (68% (n = 14)). Of these two regimes, pain flare was reported by 29% and 47% respectively.

CONCLUSION

Pain flare is a common toxicity of EBRT for bone metastases. Taking the small sample size into consideration, the incidence and duration of pain flare in patients within this single-centre study are comparable with those found in international studies.

What constitutes back pain flare? A cross sectional survey of individuals with low back pain

BACKGROUND AND PURPOSE

Low back pain (LBP) is a lifelong problem for many. In acute episodes, or as a persistent condition, LBP is fluctuating in nature, with pain and other features of the condition varying in intensity and duration over time. Symptom flares (also known as flare ups) contribute to this variation and can have a great impact on the lives of those who have LBP. An important goal of treatments for, and research on, LBP is arguably to decrease symptom flare in both frequency and severity. However, this goal is problematic with little research, and no consensus, on how to define LBP flare. In particular, patients' understandings of LBP flare have received limited attention in the literature. To appropriately address this issue, we sought to understand how flares are conceptualized by individuals with LBP.

METHODS

We used an inductive, predominantly qualitative methodology, conducting an online survey with 130 individuals who self-reported experiencing LBP. The survey investigated participants' views on LBP flare including its meaning, features and symptoms, and whether 'flare' and 'pain increase' were synonymous. Qualitative analysis of responses involved thematic and content analysis with descriptive statistics used for the quantitative component.

RESULTS

Our data analysis found that participants identified many aspects of a flare to be important. Qualitative analyses highlighted a number of themes including that LBP flare was conceptualized as: (1) an increase in pain and other uncomfortable sensations such as paraesthesia or muscle tension, (2) an increase in the area, quality and/or duration of symptoms, (3) a reduction in physical, cognitive and/or social functioning, and (4) negative psychological and/or emotional factors. Flare was also discussed as a change that was difficult to settle. When participants considered whether 'flare' and 'pain increase' were synonymous, responses were evenly divided between 'no' (47%) and 'yes' (46%) with remaining participants 'unsure'.

CONCLUSIONS

The key finding was that many people with LBP do not consider their condition to be flared simply on the basis of a pain increase. In general, other features were required to also change. Results highlighted that a narrow focus on pain is unlikely to differentiate minor pain events from a flare. These findings are important as they contrast with most commonly used definitions of a flare that focus predominantly on pain increase.

IMPLICATIONS

Our findings have implications for understanding the trajectory of LBP over time. Understandings derived from perspectives of individuals with LBP highlight that defining flare in LBP is complex. In order to provide person-centred care, individual context and experiences should be taken into account. Therefore, understandings of LBP flare require consideration of factors beyond simply an increase in pain. A comprehensive, person-centred understanding of flare that includes a number of features beyond simply an increase in pain intensity is likely to be useful to better identify flares in research settings, assisting endeavours to understand and reduce LBP. Similarly, in clinical settings a nuanced conceptualisation of flare is likely to help health professionals communicate understandings of flare when working with individuals to manage their LBP.

Incidence of pain flare in radiation treatment of bone metastases: A literature review

PURPOSE

Pain flare is a temporary increase in pain and is a potential side effect of radiotherapy treatment. However, its incidence has been reported only in recent studies, and with great variability. A few studies have reported on the use of dexamethasone as a prophylactic agent in the prevention of pain flare. The objective of this study is to present a review of the available literature regarding the incidence of pain flare and use of dexamethasone as a preventative measure.

METHODS

A literature search was conducted in PubMed using subject keywords including: "radiation therapy", "stereotactic radiation therapy", "bone metastases", "pain flare", and "dexamethasone". The search was limited to English only but not restricted to any time period. Additionally, a search was also conducted in the American Society for Therapeutic Radiology and Oncology (ASTRO) 2014 book of published abstracts. Inclusion criteria were primary studies published with full text and/or abstracts only. Letters to the editor were excluded.

RESULTS

A total of 11 studies were selected, two of which were abstracts published by ASTRO in 2014. Seven articles investigated pain flare and/or dexamethasone use for conventional external beam radiation therapy (EBRT) while the remaining four investigated stereotactic body radiation therapy (SBRT). Pain flare incidence ranged from 2 to 44% for EBRT and 10 to 68% in SBRT. The use of dexamethasone also showed to be effective in both the prophylaxis and treatment of pain flare.

CONCLUSIONS

Pain flare has been established as an acute toxicity of both EBRT and SBRT, although its incidence is widely variable due to differences in data collection. The use of dexamethasone in the prophylaxis of pain flare is efficacious. Future studies are required in order to both optimize the reporting of pain and the dexamethasone regimens in the prevention of pain flare.